HEALTH CARE AUTHORITY

(Washington Apple Health)

This section describes the health care for workers with disabilities (HWD) program.

(1) The HWD program provides categorically needy (CN) scope of care as described in WAC ((388-501-0060)) 182-501-0060.

(2) The ((department)) medicaid agency approves HWD coverage for twelve months effective the first of the month in which a person applies and meets program requirements. See WAC ((388-475-1100)) 182-511-1100 for "retroactive" coverage for months before the month of application.

(3) A person who is eligible for another medicaid program may choose not to participate in the HWD program.

(4) A person is not eligible for HWD coverage for a month in which the person received medicaid benefits under the medically needy (MN) program.

(5) The HWD program does not provide long-term care (LTC) services described in chapters ((388-513 and 388-515)) 182-513 and 182-515 WAC. LTC services include institutional, waivered, and hospice services. To receive LTC services, a person must qualify and participate in the cost of care according to the rules of those programs.

This section describes requirements a person must meet to be eligible for the health care for workers with disabilities (HWD) program.

(1) To qualify for the HWD program, a person must:

(a) Meet the general requirements for a medical program described in WAC ((388-503-0505)) 182-503-0505 (3)(a) through (f);

(b) Be age sixteen through sixty-four;

(c) Meet the federal disability requirements described in WAC ((388-475-1150)) 182-511-1150;

(d) Have net income at or below two hundred twenty percent of the federal poverty level (FPL) (see WAC ((388-478-0075)) 182-511-1060 for FPL amounts for medical programs); and

(e) Be employed full or part time (including self-employment) as described in WAC ((388-475-1200)) 182-511-1200.

(2) To determine net income, the ((department)) medicaid agency applies the following rules to total gross household income in this order:

(a) Deduct income exclusions described in WAC ((388-475-0800, 388-475-0820, 388-475-0840, and 388-475-0860)) 182-512-0800, 182-512-0820, 182-512-0840, and 182-512-0860; and

(b) Follow the CN income rules described in:

(i) WAC ((388-475-0600)) 182-512-0600, SSI-related medical—Definition of income;

(ii) WAC ((388-475-0650)) 182-512-0650, SSI-related medical—Available income;

(iii) WAC ((388-475-0700)) 182-512-0700 (1) through (5), SSI-related medical—Income eligibility;

(iv) WAC ((388-475-0750)) 182-512-0750, SSI-related medical—Countable unearned income; and

(v) WAC ((388-506-0620)) 182-512-0960, SSI-related medical clients.

(3) The HWD program does not require an asset test.

(4) Once approved for HWD coverage, a person must pay ((his/her)) the monthly premium in the following manner to continue to qualify for the program:

(a) The ((department)) agency calculates the premium for HWD coverage according to WAC ((388-475-1250)) 182-511-1250;

(b) If a person does not pay four consecutive monthly premiums, the person is not eligible for HWD coverage for the next four months and must pay all premium amounts owed before HWD coverage can be approved again; and

(c) Once approved for HWD coverage, a person who experiences a job loss can choose to continue HWD coverage through the original twelve months of eligibility, if the following requirements are met:

(i) The job loss results from an involuntary dismissal or health crisis; and

(ii) The person continues to pay the monthly premium.

This section describes requirements for retroactive coverage provided under the health care for workers with disabilities (HWD) program.

(1) Retroactive coverage refers to the period of up to three months before the month in which a person applies for the HWD program. The ((department)) medicaid agency cannot approve HWD coverage for a month that precedes January 1, 2002.

(2) To qualify for retroactive coverage under the HWD program, a person must first:

(a) Meet all program requirements described in WAC ((388-475-1050)) 182-511-1050 for each month of the retroactive period; and

(b) Pay the premium amount for each month requested within one hundred twenty days of being billed for such coverage.

(3) If a person does not pay premiums in full as described in subsection (2)(b) for all months requested in the retroactive period, the ((department)) agency denies retroactive coverage and refunds any payment received for those months.

This section describes the disability requirements for the two groups of individuals that may qualify for the health care for workers with disabilities (HWD) program.

(1) To qualify for the HWD program, a person must meet the requirements of the Social Security Act in section 1902 (a)(10)(A)(ii):

(a) (XV) for the basic coverage group (BCG); or

(b) (XVI) for the medical improvement group (MIG).

(2) The BCG consists of individuals who:

(a) Meet federal disability requirements for the supplemental security income (SSI) or Social Security Disability Insurance (SSDI) program; or

(b) Are determined by the ((division of disability determination services (DDDS))) developmental disabilities administration (DDA) to meet federal disability requirements for the HWD program.

(3) The MIG consists of individuals who:

(a) Were previously eligible and approved for the HWD program as a member of the BCG; and

(b) Are determined by DDDS to have a medically improved disability. The term "medically improved disability" refers to the particular status granted to persons described in subsection (1)(b).

(4) When completing a disability determination for the HWD program, ((DDDS)) DDA will not deny disability status because of employment.

This section describes how the ((department)) medicaid agency calculates the premium amount a person must pay for health care for workers with disabilities (HWD) coverage. This section also describes program requirements regarding the billing and payment of HWD premiums.

(1) When determining the HWD premium amount, the ((department)) agency counts only the income of the person approved for the program. It does not count the income of another household member.

(2) When determining countable income used to calculate the HWD premium, the ((department)) agency applies the following rules:

(a) Income is considered available and owned when it is:

(i) Received; and

(ii) Can be used to meet the person's needs for food, clothing, and shelter, except as described in WAC ((388-475-0600(5), 388-475-0650, and 388-475-0700(1))) 182-512-0600(5), 182-512-0650, and 182-512-0700(1).

(b) Loans and certain other receipts are not considered to be income as described in 20 C.F.R. Sec. 416.1103, e.g., direct payment by anyone of a person's medical insurance premium or a tax refund on income taxes already paid.

(3) The HWD premium amount equals a total of the following (rounded down to the nearest whole dollar):

(a) Fifty percent of unearned income above the medically needy income level (MNIL) described in WAC ((388-478-0070)) 182-519-0050; plus

(b) Five percent of total unearned income; plus

(c) Two point five percent of earned income after first deducting sixty-five dollars.

(4) When determining the premium amount, the ((department)) agency will use the current income amount until a change in income is reported and processed.

(5) A change in the premium amount is effective the month after the change in income is reported and processed.

(6) For current and ongoing coverage, the ((department)) agency will bill for HWD premiums during the month following the month in which coverage is approved.

(7) For retroactive coverage, the ((department)) agency will bill the HWD premiums during the month following the month in which coverage is requested and necessary information is received.

(8) If initial coverage for the HWD program is approved in a month that follows the month of application, the first monthly premium includes the costs for both the month of application and any following month(s).

(9) As described in WAC ((388-475-1050)) 182-511-1050 (4)(b), the ((department)) agency will close HWD coverage after four consecutive months for which premiums are not paid in full.

(10) If a person makes only a partial payment toward the cost of HWD coverage for any one month, the person remains one full month behind in the payment schedule.

(11) The ((department)) agency first applies payment for current and ongoing coverage to any amount owed for such coverage in an earlier month. Then it applies payment to the current month and then to any unpaid amount for retroactive coverage.